The hole-in-the-middle

by Philip Boxer

The blog on the health service distinguished between three levels of involvement with the patient moving from (1) being centred on providing specific treatments, to (2) being centred on episodes of care, to (3) being centred on the patient’s experience of care over time. These are levels originally separated out by the paper by Prahalad and Ramaswamy on The New Frontier of Experience Innovation. They made the more general distinction between competing in a product space, a solution space and an experience space.

The point they were making was that the third of these required a fundamentally different approach to the relationship to the customer, which I have described in terms of rcKP and the third asymmetry.

The blog gave an account of this difference in terms of changes in level of governance architecture – from the relatively internal concerns of the first two levels with the governance of care provision and of clinical referral pathways, to the through-the-life-of-the-condition concern with the patient’s care at the third level. It then concluded that this third form of governance:

“… in turn requires forms of support and transparency that can enable such change to happen, by providing funding for the transition, by providing support for this way of working out how to effect change, and by ensuring that the changes made can be sustained in a way that is accountable.”

Putting this together into a 3 x 3 creates a value stairs – establishing where you are and where you need to be on this value stairs, given the competitive asymmetries in force, is fundamental to deciding how to exploit the three potential asymmetries. Working with another client gave another perspective on the challenges involved – a telecommunications service provider whose role it was to provide just such forms of support and transparency.

In this case the levels in the value stairs were expressed in terms of the contractual framework within which the relationship with the customer unfolded over time. What characterised the resultant space as a whole was that the bottom-left three squares were very efficiently occupied by the enterprise on the basis of commodity services, while the top-right three were provided on a cottage industry basis by a high value-adding consultancy and bespoke services to relatively small numbers of large enterprises.


Given that competitive forces were driving the enterprise up the value stairs, the challenge had become the hole-in-the-middle. This was too expensive to satisfy by using the bespoke approach used top-right, and the variety of demands too complex to be satisfied using the bottom-left commoditised basis. In terms of what we need to learn about complex systems, the challenge was to find ways of operating in the collaborative quadrant below:

What was the answer? To start with, the whole business infrastructure had to be digitised so that it could be offered on a service-oriented basis. Then to leverage this capability, different ways of managing the relationship with the customer had to be found – the enterprise had to develop an approach to managing this infrastructure that could be dynamically customised from the edge of the business. This they are still in the process of doing.

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